2 Overhead athletes subject their shoulder to tremendous forces during competitionDuring the late cocking phase of throwing the arm may achive 170 to 180 degrees of ext. rotation to generate the torque required

3 Internal Impingement - DefinitionInjury and dysfunction due to repeated contactbetween the undersurface of the rot cuff tendons and the posterosuperior glenoidWalch JSES 1992

4 Internal ImpingementSome contact between these structures is physiologic but repetitive contact with altered shoulder mechanics may be pathologic

5 Internal ImpingementFor undefined reasons this contact in some athletes become pathologic and produces symptoms

11 Internal impingementSLAP lesions are not caused by internal impingement, they are rather the result of excessive torsional stress to the biceps anchorOnce produced SLAP lesions may increase the anterior translation of the humeral head up to 6 mm and the strain to the inferior glenohumeral ligament up to 100%

12 It is essentially an overuse injury associated with overhead athletesInternal ImpingementIt is essentially an overuse injury associated with overhead athletes

13 Internal Impingement Typically symptoms are present only while playingNo symptoms with activities of daily livingRepresents about 80% of the problems seen in the overhead athletes

21 Internal Impingement – Clinical ExaminationPalpation:pain can be elicited over the infraspinatouspain worse posteriorly than on GT, (vice versa on rot cuff tendonitis)Anterior part of the shoulder, biceps groove and tendon are not painful.No bony abnormalities.

28 Internal Impingement – Clinical ExaminationRelocation test of Jobe:Pain in the posterior joint line when the arm is brought in abduction external rotation with the patient supine that is relieved when a posterior directed force is applied to the shoulder

31 Internal Impingement – Differential DiagnosisRot cuff tendonitis or bursitisPain usually worse the day AFTER activity than DURING the actual event.Typically deep soreness.Unlikely internal impingement pain is more diffuse and not localized to the posterior aspect of the shoulder.Difficulty in lifting the arm, pain at the GT, that improves with rest and NSAID after a short period.Throwers’ exostosis (Bennett’s lesion).Pain at the posterior part of the shoulder (more toward the inferior than the superior aspect of the shoulder).Ceases with rest.Radiographs can help (stryker notch view= calcification at the posteroinferior glenoid rim consistent with an exostosis).

47 Internal Impingement – Surgical TreatmentSubacromial decompression22% of throwing athletes returned to the same level of participation after subacromial decompressionTibone ,Jobe. CORR 1985

48 Take home messagesInternal Impingement is a relatively common problem in overhead athletesDifficult to treatCaused by repetitive contact between the undersurface of the rot cuff and posterosuperior glenoid